Roles and responsibilities chart: Stroke activation and ...



KHSC-KGH Roles and Responsibilities Chart:

Stroke Activation and Administration of rt-PA Protocol, Endovascular Thrombectomy (EVT), or rt-PA+EVT

Dec 2003- updated May 23, 2018

|Function |Components |Responsible Person |

|Communication re: activation of |Pre-hospital pre-notification: Communicate with Regional Stroke Center ED. Upon scene |Paramedic |

|Acute Stroke Protocol |departure, advise KGH that Stroke Protocol is en route and estimated time of arrival | |

| |Additional updates to ED while en route to include establishment of IVs or if patient | |

| |becomes unstable | |

| |Call or delegate a KGH staff member to call Switchboard to alert Stroke Team: Stroke |ED Charge Nurse |

| |Protocol - XX minutes out | |

| |Initiate Stroke Protocol call |Switchboard |

| |Call KHSC-KGH staff listed in Appendix A | |

| |Ensure that all members on the Stroke Team are aware that patient is on the way to the | |

| |ED, and estimated time of arrival | |

|Communication re: External Calls |Page the Neurologist on Call for Stroke and the EVT Interventional Radiologist on Call |Switchboard |

|Requesting EVT Stroke Team (e.g.,|(see Appendix B) | |

|from Telestroke, CritiCall, | | |

|BGH-QHC) | | |

| |If EVT is possible, contact Switchboard to initiate Stroke Protocol |Attending Neurologist |

| |If patient is unstable/intubated, also contact Kidd 2 ICU Intensivist and Kidd 2 ICU | |

| |Charge Nurse and ED Charge Nurse | |

| |RT will be notified if patient is intubated by ICU team | |

|Patient Registration |Register patient as soon as patient arrives in ED |ED Registration Clerk |

|Initial ED evaluation including |Ambulance triage in ED |Triage-trained Nurse |

|medical screening by ED physician|If patient walks into ED, perform rapid triage with recognition of stroke symptoms | |

|or Neurologist |Ask ED Registration Clerk to register patient if not already done | |

| |Notify CT of patient’s arrival in ED |ED Charge Nurse |

| |ED physician or Neurologist ensures that KGH staff member has notified CT of patient’s |ED Unit Clerk |

| |arrival in ED | |

| |Upon patient arrival at central desk near Section A: | |

| |Paramedic reports last seen well, symptoms, medical conditions and medications if | |

| |available, vital signs and glucometer reading |Paramedic |

| |ED physician or Neurologist does immediate medical screen to ascertain if patient is | |

| |potential stroke patient |Attending Neurologist or ED |

| | |Physician-first to arrive |

|Stroke Call cancellation if |After arrival in the ED and ED physician or Neurologist has done initial screen, if |ED Charge Nurse |

|needed |stroke activation is to be cancelled, notify or delegate a KGH staff member to call | |

| |Switchboard | |

| |Switchboard repeats calls to those listed in Appendix A and notes “Stroke Protocol | |

| |cancelled” |Switchboard |

|CT Readiness |Ensure that patient is “next on scan”, and that CT scan is ready for stroke patient |CT Technologist |

| |within 10 minutes of arrival to ED | |

|Repatriation planning |If Attending Physician suspects that patient may not be a rt-PA or EVT candidate, and |Attending Neurologist or ED |

| |will qualify for repatriation back to a bypassed community hospital ED, Dispatch will be|Physician |

| |immediately contacted to request that the EMS crew be held up to regulated timeframe, | |

| |while decision is made as to rt-PA +/-EVT candidacy, medical stability and medical | |

| |diagnosis | |

|Medical assessment and clinical |Initial assessment re: candidacy for rt-PA administration and/or EVT |Attending Neurologist |

|decision making |Completion of NIH Stroke Scale (included in the Stroke Assessment form found in Stroke |Neurology House staff under |

| |Protocol package) |supervision of Attending |

| | |Neurologist |

|Preparation of patient before CT |Print blood labels |ED Nurse |

|Scan |2 peripheral IVs - (1 IV with 18 Gauge needle in Rt. ACF is preferred- if unable, use 20| |

| |Gauge; must be above the hand) | |

| |Bloodwork sent to lab using Acute Stroke Protocol package yellow labeled blood tubes. | |

| |Attending Physician directs Nurse to draw bloodwork before or after CT. Waiting for | |

| |bloodwork results is not mandatory to make decision for rt-PA +/-EVT | |

|POC INR |When possible, obtain INR using Point-of-Care (POC) device. Quality assurance check to |Attending Neurologist |

| |be done q 24 hours | |

|Lab Blood Work |Lab processes bloodwork STAT and informs ED of results ASAP |Lab |

|Patient Transport to CT Suite |Patient to remain on EMS stretcher until CT |ED Nurse |

| |Follow patient to CT suite with ED stretcher, monitor, pump, transport kit, and rt-PA | |

| |from Omnicell | |

| |Transport patient to CT suite |Stroke Team |

| |Prior to CT scan, switch paramedic’s monitor to ED monitor in CT suite, check leads are |ED Nurse |

| |moved away from center chest area | |

| |Ensure jewelry, dentures, and hearing aids are removed | |

| |Care for patient in CT Suite | |

| |Before Paramedics leaves KGH, report is given to ED Nurse |Paramedic |

|Consent processes |Patent and family education is ongoing to prepare for consent |Attending Neurologist |

|Consent for CT+/-CTA |Verbal consent is obtained for IV contrast for CTA if this is to be used, and is |CT Technologist |

| |documented in chart. If verbal consent cannot be obtained, emergency consent procedures | |

| |are followed and documented | |

|Medical Management & Decision |Neurologist views CT scan +/-multiphase CTA with Neuroradiology |Attending Neurologist |

|Making |Inclusion/Exclusion Criteria for rt-PA is used to determine rt-PA candidacy | |

| |Neurologist will use ESCAPE trial criteria and KGH Stroke EVT Checklist to determine | |

| |candidacy for EVT | |

| |If patient is candidate for administration of rt-PA and/or EVT, then patient will be | |

| |transferred to Neurology Service | |

| |Medical management and clinical decision-making surrounding initial and any additional | |

| |radiological imaging performed (i.e., CT Perfusion, MRI, MRA, Angiography). | |

| |Interpretation of imaging. Decisions re indications for pursuing additional diagnostic | |

| |imaging. This is done keeping “time is brain” in mind | |

| |Accountability regarding clinical interpretation of diagnostic imaging and decision | |

| |regarding treatment choice re: administration of IV or IA rt-PA, and/or EVT | |

| | |Attending Neurologist and |

| | |Interventional Radiologist |

| | |(when appropriate) |

|Communication re rt-PA +/-EVT & |If the patient is a candidate for IV rt-PA: |Attending Neurologist ED Charge|

|Bed Planning |Notify D4ICU Charge Nurse |Nurse |

| |If the patient is a candidate for EVT +/-rt-PA: | |

| |Notify Interventional Radiologist |Attending Neurologist |

| |Notify IR Technologist and IR Charge Nurse |Interventional Radiologist |

| |After hours: Call back EVT team via Switchboard see Appendix B | |

| |Notify ICU Intensivist |Attending Neurologist |

| |If after hours and patient returning to ED, notify ED Charge Nurse |ED Nurse |

| |Notify Administrative Coordinator to locate or confirm critical care bed in D4ICU or | |

| |K2ICU |IR Charge Nurse or Attending |

| | |Neurologist if after hours |

|IR suite triaging |In cases of more than one patient requiring emergent IR procedures in IR suite, clinical|Daily Operations Team for IR |

| |decision & plan regarding most appropriate triage care must be executed in consultation |Suite with Attending |

| |with all Attending Physicians responsible for care of all patients requiring emergent IR|Neurologist |

| |procedures. Triage follows the principle that EVT/ IA rt-PA in appropriate stroke | |

| |patients is an Emergency | |

|For patients who are not |If patient's clinical situation is not appropriate for administration of rt-PA +/-EVT, | |

|candidates for rt-PA |then patient may: |Attending Neurosurgery |

|administration +/-EVT: admission |be transferred to neurosurgery |Attending Neurologist |

|or repatriation from ED |be admitted via neurology to KGH Acute Stroke Unit – using order sets for those not | |

| |receiving rt-PA |Attending ED Physician |

| |remain under care of ED physician while arrangements are made for patient to be | |

| |repatriated back to local bypassed ED | |

| |In the case of C) ED to ED repatriation | |

| |Dispatch must be immediately notified regarding the repatriation transport needs of the | |

| |patient | |

| |Criteria for repatriation from KGH ED to bypassed ED site: | |

| |Established medical diagnosis | |

| |Patient no longer needs tertiary care | |

| |Investigations that are NOT available at local facility are complete | |

| |Communication has occurred with patient/family/substitute decision-maker | |

| |Reminder: D4ICU Charge Nurse or K2ICU Charge Nurse and Administrative Coordinator should| |

| |be notified if a critical care bed is not needed for the patient | |

| | |ED Charge Nurse |

|Obtain consent for |NOTE: this process begins PRIOR to CT to prepare for timely decision post CT. |Attending Neurologist |

|IV rt-PA |Patient or substitute decision-maker is provided appropriate and specific information | |

| |regarding risks and benefits of the planned procedure, and sufficient time is given to | |

| |patient/family to give informed consent | |

| |For IV rt-PA administration verbal consent is obtained from patient or substitute | |

| |decision- maker | |

|EVT +/- IV rt-PA or |For EVT +/-IV rt-PA or IA rt-PA administration written consent is obtained from patient |Attending Neurologist and |

|IA rt-PA consent |or substitute decision-maker using appropriate Radiology Consent Form |Interventional Radiologist |

| |Part A: Explained to patient and consent obtained by Neurologist | |

| |Part B: Explained to patient and consent obtained by Interventional Radiologist | |

|IV rt-PA or EVT +/-IV rt-PA or IA|If patient is unable to consent, and there is no substitute decision- maker at KGH, |Attending Neurologist |

|rt-PA if unable to consent |verbal consent over the telephone may be obtained from substitute decision-maker | |

| |In a case where patient is unable to give consent, and substitute decision-maker cannot | |

| |be contacted, Neurologist and Interventional Radiologist (if EVT, IA rt-PA) is | |

| |responsible for making decision to treat patient based on clinical judgment |Attending Neurologist and |

| |Rationale for treatment decision and reasons why consent could not be obtained must be |Interventional Radiologist (if |

| |documented |EVT, IA rt-PA) |

| |Fill in and sign Emergency Consent Form | |

|Consent withdrawal |Responsibility to assess and communicate with patient or substitute decision-maker in |Attending Neurologist (for IV |

| |circumstances where consent is withdrawn during rt-PA administration +/-EVT |rt-PA) |

| |Clinical reassessment as part of ongoing monitoring and confirmation of consent |Attending Neurologist and |

| |Assess competency to provide consent |Interventional Radiologist (for|

| | |EVT, IA rt-PA) |

|If IV rt-PA is Administered without EVT |

|Administration of IV rt-PA in CT |Direct ED RN to prepare for IV rt-PA |Attending Neurologist |

|Suite |Write order for IV rt-PA in chart/Entry Point |Neurology House staff under |

| |Administer IV bolus dose of rt-PA, begin infusion with assistance of ED Nurse |supervision of Attending |

| | |Neurologist |

|Patient assessment & monitoring |Follow Acute Ischemic Stroke CCP re IV rt-PA |ED Nurse |

|during and following rt-PA |IV rt-PA infusion start in CT Suite | |

|infusion (IV and IA) |Transport patient back to ED after CT Scan | |

| |CNS Scale & VS q 15 min for 2 hours then q 1 hour for 22 hours, follow CCP | |

| |Assess patient’s airway, comfort, and level of consciousness, sedation, and agitation | |

| |Continuous SpO2 & cardiac monitoring | |

| |Monitor for angioedema & bleeding | |

| |Keep patient NPO | |

| |Change patient into hospital gown | |

| |ECG post initiation of IV rt-PA infusion | |

|Patient transfer to D4ICU bed |Acute Ischemic Stroke Thrombolysis/EVT QBP Order Set is completed in Entry Point |Attending Neurologist |

| |Communicate with D4ICU Charge Nurse re: bed planning; stroke patients’ readiness for | |

| |transfer |ED Charge Nurse |

| |Monitor in accordance with Acute Ischemic Stroke CCP while awaiting transfer to Unit | |

|If EVT with or without rt-PA |

|Clinical decision re EVT |Decision to proceed with EVT after multiphase CTA is interpreted |Attending Neurologist |

| | |and Interventional Radiologist |

|Communication & Bed Location |Notify family-inform family to wait in IVR Waiting Room |IR Charge Nurse or IR Nurse or |

| |Notify CT Suite or ED that IVR suite is ready |Technologist if after hours |

| | |D4ICU or K2ICU Charge Nurse |

| |D4ICU or K2ICU Charge Nurse informs IVR of bed location | |

| |Contact Administrative Coordinator if delay in locating bed | |

|Patient to receive IV rt-PA |See above for IV rt-PA |IR Nurse |

| |Prepare IVR Suite while patient is receiving IV rt-PA in CT or ED |IR Nurse and IR Technologist |

|Prepare patient for EVT +/-IA |Ensure patient is in hospital gown with no underwear |ED Nurse +/-IR Nurse |

|rt-PA procedure |If potential candidate for EVT, insert foley catheter (if patient is to receive rt-PA, | |

| |insert foley catheter prior to rt-PA) | |

| |Ensure 2 working IVs | |

| |Transport patient to IVR when IVR suite is ready | |

| |Prepare patient for procedure including: |IR Nurse |

| |Place patient on continuous SpO2 & cardiac monitoring | |

| |Shave prep both groins-only if absolutely necessary | |

| |Administer conscious procedural sedation & follow Procedural Sedation Policy& IVR | |

| |Procedure Order Set | |

|Monitor patient during procedure |Follow standard IVR care processes including: |Interventional Radiologist and |

| |Continuous SpO2 & Cardiac monitoring |IR Nurse |

| |BP monitoring | |

| |Assess patient’s airway, comfort, and level of consciousness, sedation, and agitation | |

| |Monitor for angioedema and bleeding | |

| |Keep patient NPO | |

|Medical management of patient in |As a general principle, patients undergoing procedures are under the immediate care of |Interventional Radiologists |

|IVR suite |the procedural physician although that physician may seek consultative support from |with consultation as required |

| |referring and other physicians |with the Attending Neurologist |

| |IR Technologists and IR Nurses assist with procedure | |

| |Attending Neurologist is available in IVR suite to assist as needed | |

| |Decision making regarding modifying/aborting planned EVT procedure | |

|Medical Management of Sedation |Ordering sedation and analgesia as required per IVR Procedure Order Set (Adult) |Neurologist with Interventional|

| |When no Anesthesiologist is present, medical management of a patient who develops |Radiologist |

| |complications in IVR suite, including consultation of other medical services (i.e. | |

| |Anesthesiology) is initiated by Interventional Radiologist in consultation with the | |

| |Neurologist | |

| |If there is concern about patient’s airway or LOC in the IVR suite, a code 99 for | |

| |Anesthesiology is to be called | |

| |If patient arrives intubated, decision is made to contact Anesthesiology as needed | |

| |If Anesthesiologist is present, patient monitoring, sedation and analgesia will be |ICU Intensivist |

| |responsibility of the Anesthesiologist | |

| | | |

| | |Anesthesiologist |

|Femoral Sheath Removal |Check ACT & remove sheath per IVR Femoral Arterial Sheath Removal Nursing Policy & |IR Nurse |

| |Procedure & Arterial Sheath Removal Order Set | |

| |Apply bandage to puncture site | |

| |If Angio-Seal is not applied post procedure and femoral sheath remains in situ-complete | |

| |Arterial Sheath Removal Order Set |Interventional Radiologist |

| |IR Nurse removes femoral sheath wherever the patient is located per Arterial Sheath |IR Nurse |

| |Removal Order Set | |

|For Cases Where EVT is Aborted |In the case that EVT is aborted, the Administrative Coordinator is contacted to locate |Attending Neurologist |

| |appropriate bed | |

|Transfer patient to Davies 4 ICU |Notify D4ICU Charge Nurse or K2ICU Charge Nurse when procedure is completed |IR Charge Nurse or IR Nurse if |

|or K2 ICU |Contact Administrative Coordinator if delay in locating bed |after hours |

| |Handover report in IVR to K2ICU Nurse/ICU Intensivist if patient going to K2ICU bed | |

| |IR Nurse returns ED portable monitor to ED | |

| |Transfer patient with Stroke Team to D4ICU or K2ICU | |

| |Neurologist gives hand over report once patient has been transferred to D4ICU or K2ICU | |

| | | |

| | |Attending Neurologist |

|Protocol Coordination |

|Protocol Coordination Functions |Facilitate Stroke Protocol as it relates to external bodies (ambulance services, base |Regional Director & Regional |

| |hospital, central ambulance communication center, paramedics, other hospitals) |Stroke Best Practice |

| | |Coordinator, Stroke Network of |

| | |Southeastern Ontario |

| | | |

| |Facilitate the Stroke Protocol internally |Stroke Specialist Case Manager |

| | |and Stroke Neurologist |

Appendix A

Acute Stroke Protocol Team Activation by Switchboard

DAYS:

Staff Neurologist on Call and Neurology Fellow

Neuroradiologist

PGY2 (or PGY1 if PGY2 is post call)

ED Charge Nurse

ED Registration Clerk

Administrative Coordinator

Stroke Specialist Case Manager (page)

CT technologist

Admitting

Core Lab

Regional Director, Stroke Network of Southeastern Ontario (leave message)

After hours, weekends, and holidays:

Staff Neurologist on Call

Neurology Fellow (if on call)

Radiology resident on call

ED Charge Nurse

ED Registration Clerk

Administrative Coordinator

CT technologist (on call)

Admitting

Core Lab

Stroke Specialist Case Manager (leave message)

Regional Director, Stroke Network of Southeastern Ontario (leave message)

When all have confirmed, call ED and report, “all have confirmed”.

Appendix B

Switchboard Guide: Endovascular ‘EVT’ Stroke Team External call Requesting EVT

-----------------------

External call requesting “Endovascular (EVT) Stroke TEAM”

Calls for EVT can originate from – TELESTROKE, CRITICALL, Belleville General, Quinte Health Care

(or ED)

NO MATTER HOW a caller ASKS for EVT stroke—We page BOTH the NEUROLOGIST on call for STROKE and the EVT Interventional Radiologist (IR) on call.

Call goes to Neurologist on call for STROKE and the EVT Interventional Radiologist on call

If stroke patient is already at KGH and Stroke protocol has been activated, the Neurologist is already treating patient and EVT treatment might be considered

Interventional Radiologist (IR) and Stroke Doctors will connect with CritiCall and/or the referring team will look at patient’s scan and decide if EVT is possible.

If YES EVT

If NO EVT

Neurologist will request stroke protocol activation

PAGE GROUP # IVR TEAM for EVT 613-536-7557

Consists of 3 team members

2 IVR Techs and 1 IVR Nurse

Plus back-up stroke neurologists Dr Jin and Dr Appireddy

After hours, the IR Attending may call switchboard and request we notify the IVR team for EVT (stroke)

***PLS Note—NO ONE OTHER THAN the Interventional radiologist Attending can request IVR TEAM for EVT call- back activation

If the Endovascular Team (Neuro and IR) think EVT is possible two things happen:

1. Neurologist will ask for stroke protocol activation to notify team

2. IR Attending may need to request IVR EVT team call back

No further action to be taken

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